Diabetes Research and Clinical Practice, 15 (1992) 157-162 0
1992 Elsevier Science Publishers
157
B.V. All rights reserved 0168-8227/92/$05.00
DIABET 00588
Behaviour modification in obese subjects with type 2 diabetes mellitus A.L. Calle-Pascual ‘, C. Rodriguez ‘, F. Camacho I, R. Sanchez ‘, P.J. Martin-Alvarez2, E. Yuste ‘, I. Hidalgo 3, R.J. Diaz 3, J.R. Calle4 and A.L. Charro4 ’ Unit of Endocrinology and Nutrition, ‘C.S. I.C. Madrid, ‘Psychiatric Unit, Hospital Ntra Sra de Sonsoles, University of Salamanca,
Avila and 4Hospital Clinic0 Universitario, Madrid, Spain
(Received 29 June 1990) (Revision accepted 11 September
1991)
Summary We have followed prospectively, 46 obese, type 2 diabetic patients for a 55-week period, in order to evaluate the efficiency of an educational programme based on behaviour modification to enhance weight loss and changes of other cardiovascular risk factors. No patient received pharmacological treatment during the study. At the end of the follow-up the patients obtained an average weight loss of 9.250 kg (range: 0.500-17.500 kg); the BMJ was reduced from 34.2 + 0.8 kg/m2 to 30.6 + 1.1 kg/m2 (P < 0.01); fasting serum glucose descended from 7.9 + 0.4 to 6.1 k 0.5 mM (P < 0.05); SBP (systolic blood pressure) decreased from 145.7 + 3 to 126.4 k 5.1 mmHg (P < 0.01); DBP (diastolic blood pressure) decreased from 83.5 ? 2.5 to 65 + 2.6 mmHg (P < 0.01); triglyceride levels were lowered from 164.5 & 12 to 109.7 k 10 mg/dl (P < 0.01); HDL-cholesterol levels increased from 1.27 k 0.05 to 1.53 k 0.12 mM (P < 0.01). Serum glucose 2 h after a 75 g glucose oral load decreased from 14.9 + 0.6 to 12.7 k 0.9 mM (P < 0.05) on week 35 of follow-up. Twelve patients no longer presented a diabetic curve (8 normal oral glucose tolerance test (OGTT) curves, and 4 impaired glucose tolerance (IGT) curves). No significant changes in the parameters studied were obtained in the group of patients on conventional treatment. Patients from the intervention group losing less than 4 kg of body weight displayed an increase in dependence and social introversion scores according to the Minnesota multiphasic personality inventory (MMPI) compared to those who lost more than 4 kg (possibly as a consequence of failure to attain the aims of the educational programme). Our results permit us to conclude that an educational programme using behaviour modification can be useful in the weight reduction of obese type 2 diabetic patients, thereby improving blood glucose control and reducing other cardiovascular risk factors.
Key words: Behaviour
modification;
Correspondence to: A.L. Calle-Pascual, Lagos s/n, 28040 Madrid, Spain.
Obesity; Type 2 diabetes mellitus; Cardiovascular
Servicio de Endocrinologia
y Nutrition
risk factor
2%, Hospital Clinic0 Universitario,
c/-Martin
158
Introduction
Obesity is the most commonly-occurring nutritional disease in developed countries [ 11. It is often associated with type 2 diabetes mellitus, which increases mortality rate. However, increased death rate can be reduced by weight loss [ 21. Furthermore, 75 % of type 2 diabetic patients are obese [ 31. Weight loss can prolong life expectancy [4] and can improve glucose tolerance [ 51. For these reasons, the aim of treatment of overweight type 2 diabetic patients must be reduction of body weight as well as of other cardiovascular risk factors [6]. A retrospective study has recently demonstrated that each kg of weight lost lengthened life-expectancy by four months [4]. Yet weight loss is not easy to achieve in type 2 diabetic patients, and the results of weight reduction programmes have been contradictory [7-Ill. It has been said that diabetic patients present greater difficulty in losing weight than non-diabetic subjects [ 9, lo] implying the need for pharmacological treatment of obesity [ 121. The reasons for discrepancies in results may stem from the differences in the educational programmes used, since success is greater if followup is more intense, and more so if home visits are included [ 13-l 51. However, it may not be feasible to apply an intensive approach to large diabetic populations. Recently, the use of an educational programme with behaviour modification has been recommended for type 2 diabetic patients with obesity [ 16,171, but there are no data on the success rate of these programmes in diabetic patients. The aim of our work has been to study the efficiency of an educational programme with behaviour modification in type 2 diabetic patients with obesity on weight loss and on other cardiovascular risk factors.
Material
and Methods
We designed a prospective study in which all patients that came to our hospital between January and June, 1988 were included, provided
that the reason for consultation was obesity and that they were diagnosed as having diabetes mellitus based on a fasting serum glucose level (between 7.7 and 8.8 mM) or serum glucose response to 75 g of glucose (if the fasting serum glucose level was below 7.7 mM) in accordance with the criteria of the National Diabetes Data Group. The protocol was approved by the Clinical Trials Board and carried out following the principles of the Helsinki Declaration. No patient received pharmacological treatment during the study. Intervention group A total of 46 patients, 10 men and 36 women, fulfilled the requirements and completed the study. They were 55.09 + 9.7 years of age. The average weight was 81.21 & 1.77 kg. The BMI averaged 34.21 k 0.8 kg/m2 (M k SEM). On the first day of consultation, data about the patients’ caloric consumption were gathered retrospectively. Note was taken of what the patients had eaten during the previous week and on the previous day. We also, prospectively, analyzed and noted the diet of three non-consecutive days between the first visit and the beginning of the educational programme (one or two weeks after the first visit). Design of the educational programme The design was similar to the one used for obese patients and previously published [5]. It was taught by paramedical personnel (nurses) and consisted of four 150-180 min sessions in one week. The first session was individual and during it personal characteristics of each patient were noted. The three remaining sessions were done in groups of five to eight patients of similar age and cultural background. In these meetings we tried to modify eating behaviour. In the first meeting, patients were taught dietetic principles including food composition, calculation of caloric content, ‘filling’ capacity of different foodstuffs and calculation of caloric expenditure. The remaining two sessions were oriented towards teaching self-control over excessive eating patterns. This part of the
159
programme consisted of five phases. During phase one we tried to reinforce the patients’ selfcontrol over the need to eat. We advised postponed initiation of food ingestion in a progressive manner from one to five min, while the patient was in front of the food. In phase two the goal was to create awareness of each meal by proposing that the patient himself prepare his food. During phase three we recommended that eating was not to be simultaneous with other activities. In the fourth phase the patients were taught exercises intended to alter their cooking habits, deleting condiments and foods with high caloric content. Phase five was directed towards the detection of ‘dangerous moments’ when the patient ingested large amounts of food; we advised them to carry out simultaneous parallel activities. The patients did not receive rules nor diets in writing. Five, 10, 35 and 55 weeks after having carried out the educational programme, retraining on these latter aspects was given in group sessions. At each visit we measured body weight, blood pressure, white blood cells and red blood cells (Coulter), Na, K, Ca, P, BUN, uric acid, glucose, cholesterol, triglycerides (Hitachi, autoanalyzer) and HDL-cholesterol (enzymatic method). An OGTT with 75 g of glucose was performed at the beginning and after 5 and 35 weeks of follow-up. Psychological projile
After 55 weeks of follow-up the Minnesota MultiPersonality Inventory (MMPI) phasic questionnaire in the collective form taken from the Spanish version by TEA [ 181 was tilled out by 24 women; as a control group we chose 24 obese type 2 diabetic women at the beginning of their educational program and with a similar age and BMI. This questionnaire is designed specially to make possible an estimation of the commonly recognized syndromes in subjects with clinical problems. The superior dimensions of personality were calculated beginning with the first-order factors. Control group
Conventional treatment for obese type 2 diabetic patients on diet alone, in our clinic includes two
meetings dedicated to dietetic instruction and exercise. All patients receive tables of equivalence and a set of six diets of 1000 calories divided into 6 meals with 60% carbohydrate content. Laboratory data are obtained after each 5 kg of weight loss, and at least once a year. We show the laboratory data at 55 weeks of follow-up, because at this time these data were available for all patients. Included in this control group were 28 obese type 2 diabetic patients, 7 men and 21 women, 53.03 k 6.78 years of age, with a body weight of 80.925 & 1.59kg and with a BMI of 34.13 + 0.75 kg/m2. No patient received pharmacological agents during this year period. The statistical analysis was done using the BMDP3D program from BMDP package [ 193, in order to test the equality of group means (Student’s two-sample t-test). This program was run on a CDC Cyber 180/855 computer (Control Dada Iberica, Madrid, Spain).
Results Intervention group
The mean weight loss was 9.250 kg (range: 0.500-17.500 kg) during follow-up. The BMI decreased with statistical significance from 34.2 + 0.8 to 30.6 + 1.1 kg/m2 (P < 0.01). Likewise, after 55 weeks of follow-up, the following changes were observed: FSG (fasting serum glucose) dropped from 7.9 + 0.4 to 6.1 k 0.5 mM (P < 0.05); SBP (systolic blood pressure) fell from 145.7 _+3 to 126.4 _+5.1 mmHg (P < 0.01); DBP (diastolic blood pressure) was lowered from 83.5 _+2.5 to 65 f 2.6 mmHg (P < 0.01); triglyceride levels decreased from 164.5 k 12 to 109.7 + 10 mg/dl (P < 0.01) and HDL-cholestelevels rol rose from 1.27 _+0.05 to 1.53 2 0.12 mM (P < 0.01). The 2-h value for serum glucose after a 75 g glucose oral load decreased from 14.9 _+0.6 to 12.7 _+0.9 mM (P < 0.01) in week 35 of follow-up (Table 1). Based on the data provided by the OGTT, 12 patients ceased to be considered as having diabetes mellitus (8 normal OGTT curves and 4
160 TABLE
1
Changes in body weight and in laboratory
data during the follow-up
Time (weeks) 0 BW (kg) BMI (kg/m’) FSG (mM) 2-h OGTT (mM) SBP (mmHg) DBP (mmHg) TG (mg/dI) Chol (mM) HDL-Ch (mM) CholjHDL-Ch
81.2 & 34.2 + 1.9 * 14.9 + 145.7 f 83.5 + 164.5 f 6.12 f 1.27 k 5.0 +
5 1.7 0.8 0.4 0.6 3.0 2.5 12.0 0.14 0.05 0.2
71.5 + 32.9 f 6.7 k 13.5 & 134.7 f 15.4 + 153.7 + 5.73 + 1.17 f 5.1 +
10 1.s** 0.9** 0.3* 0.7* 3.1** 2.2** 11.0 0.16** 0.05 0.2
35
74.2 + 2.0** 31.6 k l.O** 6.5 f 0.4** 131.7 & 72.4 f 144.1 2 5.82 + 1.30 * 4.6 i
2.9** l.l** 11.0 0.20 0.05 0.2
73.1 31.3 6.7 12.7 137.4 80.5 140.2 6.17 1.29 4.9
55 f + f & * + k + + f
1.9** 1.0** 0.4** 0.9* 3.5 2.6 12.0 0.21 0.05* 0.2
71.4 + 2.0** 30.6 f l.l** 6.1 + 0.5* 126.4 65.0 109.7 6.21 1.53 4.4
f 5.1** f 2.6** f 10.0** f 0.29 f 0.12** f 0.3
BW, body weight; BMI, body mass index; FSG, fasting serum glucose level; 2-h OGTT, 2-hour serum glucose response to 75 g oral glucose load; SBP, systolic blood pressure; DBP, diastolic blood pressure; TG, triglyceride level; Chol, cholesterol level; HDL-Ch, HDL-cholesterol level. Results expressed as mean t SEM
intolerant OGTT curves). There were no significant changes in the other laboratory data studied. One year later these patients presented a significant increase in the dependence score (Dy), the higher the score, the higher the dependence on the treatment team [ 181, in comparison to those who did not receive educational courses (33.6 1 2 1.6 vs 27.78 k 1.4; P < 0.05) (this increase reflects the higher score seen in patients who did not attain a 4 kg weight loss). A higher score in the social introversion scale (the higher the score, the higher the social isolation because of their disease) was seen in patients who did not attain a 4 kg weight loss (43.66 + 2.5) compared to those patients who lost more than 4 kg of body weight (35.71 + 3.2; P < 0.05). A negative correlation between body weight loss (BWL) and dependence score (Dy = 41.28 - 4.676 BWL; Y = - 0.693; P < 0.05) and between BWL and social introversion (SI) score (SI = 46.97 - 5.049 BWL; r= - 0.772; P < 0.05) was found. Conventional treatment group Patients in conventional treatment failed to show any significant changes in the parameters studied:
body weight (80.925 & 1.59 vs 81.070 k 1.20 kg), BMI (34.13 k 0.75 vs 34.32 k 0.64 kg/m*), FSG (7.78 k 0.71 vs 7.75 k 0.46 mM), 2-h value for serum glucose after a 75 g glucose oral load (14.54 2 0.19 vs 14.48 f O.l6mM), SBP (148.03 2 3.72 vs 145.35 k 3.39 mmHg), DBP (85.35 k 2.09 vs 86.07 _I 2.02 mmHg), triglyceride levels (166.46 f 9.06 vs 163.28 2 7.76 mg/dl), cholesterol levels (6.26 f 0.06 vs 6.21 + 0.98 mM), HDL-cholesterol levels (1.29 + 0.02 vs 1.30 k 0.04 mM) and cholesterol/HDL-cholesterol ratio (4.89 + 0.12 vs 4.92 & 0.21).
Discussion Our study confirms previous results obtained with obese patients proving the efficiency of behaviour modification programmes in weight loss and in reducing other cardiovascular risk factors [ 51. Lesser caloric intake per kg of body weight of obese patients than lean people has been reported. Recently it has been said that this unexpected result cannot be explained solely by underreporting [ 20-221. Other factors can be involved
161
[23-251. We venture the hypothesis that the cornerstone of the problem is that many foods are ingested rather subconsciously by the obese person. Therefore, our programme with behaviour modification was structured in such a way as to force the patient to make an effort (e.g. preparation of the meal.. . ) before ingesting the meal, and to become aware of the activity of eating. We did not consider it appropriate to induce phobias against or adverse reactions to foodstuffs. We included notions on caloric content and expenditure to favour ingestion of foods with less calories. regular physical exercise (e.g. avoiding taking the subway or bus, or to get out of public transport one or two stops before the destination; not to use elevators, etc.) was also recommended. In order to facilitate the interpretations of the results of our educational programme, we chose obese patients diagnosed as having diabetes mellitus based on the OGTT (with a FSG level below 7.7 mM) or with a FSG level between 7.7 and 8.8 mM, thereby being ethically tolerable to have pharmacological hypoglycaemic treatment withheld. Nor did they receive anorexigenic agents. Therefore, we can state that our results are solely the consequence of the effects of the educational programme. Our patient attained a weight reduction of 9.250 kg (range 0.500-17.500 kg) and an improvement in cardiovascular risk factors. In the first 5 weeks of follow-up, we noted a non-significant decrease in total cholesterol level, at the expense of its HDL fraction, which could be due to weight reduction as well as to the acute effect of the reduction in the consumption of olive oil that is customary in the mediterranean diet [26]. Reduced olive oil intake must be taken into account when we recommend changes in the eating habits, because it could increase the atherogenic index, even if only temporarily. The weight reduction obtained by our patients produced a significant reduction in FSG levels as well as in the 2-h post-75 g oral glucose load; for this reason 12 patients were no longer considered diabetic patients at week 35 of follow-up. This confirms that simple weight loss can revert the
diabetic state [ 51. Similarly, the improvement in the other cardiovascular risk factors obtained in our study may be related to the educational programme induced weight loss as well as to modifications in eating habits (e.g. reduced salt and fat consumption) and regular physical exercise. The psychological changes found in our study were observed in the patients unable to lose weight or whose weight loss was less than 50% of the average loss. These patients had high scores in the dependence and social introversion scales. We may infer that the patients who do not reach the goals of the educational programme (e.g. lose weight) become more dependent and introverted than those who do reach the goals. This could be considered to be a side effect of the educational programme and may occur when the aims are too difficult for the patients. This fact must be taken into account when planning group education proposing variable goals. In summary, our study supports the efficiency of behaviour modification in weight reduction programmes and in reduction of cardiovascular risk factors in type 2 diabetes mellitus. Furthermore, this relatively simple programme can be applied in an ordinary medical office setting.
References Passmore, R. and Eastwood, M.A. (Eds.) (1986) Obesity. In: Human Nutrition and Diabetics. Churchill Livingstone. Edinburgh, London, Melbourne, New York, pp. 269-218. Blackburn, G.L. and Read, J.L. (1984) Benefits of reducing revisited. Postgrad. Med. J. 60, 13-18. Wing, R.R. (1989) Behavioral strategies for weight reduction in obese type II diabetic patients. Diabetes Care 12, 139-144. Lean, M.E.J., Powrie, J.K., Anderson, A.S. and Garthwaite, P.H. (1990) Obesity, weight loss and prognosis in type 2 diabetes. Diabetic Med. 7, 228-233. Calle-Pascual, A.L., Rodriguez, C., Hernandez, M.J., Martin, P.J., Yuste, E., Garcia, M.A., Matias, J., Martin, P. and Sanchez, R. (1989) Programme of education for obese patients. Preliminary results after one year. Diabete Metabol. 15, 403-408. Consensus Statement (1990) Role of cardiovascular risk factors in prevention and treatment of macrovascular
162 disease in diabetes. Diabetes Care 13 (Suppl. 1). 53-59. 7 Multi-Centre Study (1983) U.K. prospective study of therapies of maturity-onset diabetes. Diabetologia 24, 404-4 11. 8 Kronsbein, P., Miihlhauser, I., Venhaus, A., Jorgens, V., Scholz, V. and Berger, M. (1988) Evaluation of a structured treatment and teaching programme on noninsulin-dependent diabetes. Lancet ii, 1407-1411. 9 Wing, R.R., Marcus, M.D., Epstein, L.H. and Salata, R. ( 1987) Type 2 diabetic subjects lose less weight than their overweight non-diabetic spouses. Diabetes Care 10, 563-566. 10 Henry, R.R., West-Kent, T.A., Scheaffer, L., Kolterman. O.G. and Olefsky, J.M. (1986) Metabolic consequences of very low calorie diet therapy in obese non-insulin dependent diabetic and non-diabetic subjects. Diabetes 35, 155-164. 11 Glasgow, R.E., Toobert, D.J., Mitchell, D.L., Donnelly, J.E. and Calder, D. (1989) Nutrition education and social learning interventions for type II diabetes. Diabetes Care 12, 150-152. 12 Carpenter, M.A. and Bodansky, H.J. (1990) Drug treatment of obesity in type 2 diabetes mellitus. Diabetic Med. 7, 99-104. 13 Heller, S.R., Clarke, P., Daly, H., Davis, I., McCulloch, D.K., Allison, S.P. and Tattersall, R.B. (1988) Group education for obese patients with type 2 diabetes. Greater success at less cost. Diabetic Med. 5, 552-556. 14 Hadden, D.R., Blair, A.L.T., Wilson, E.A. et al. (1986) Natural history of diabetes presenting age 40-69 years: a prospective study of the influence of intensive dietary therapy. Quart. J. Med. 59, 579-598. 15 Wilson, E.A., Hadden, D.R., Merrett, J.D., Montgomery, D.A.D. and Weaver, J.A. (1980) Dietary management of maturity-onset diabetes. Br. Med. J. 280, 1367-1369. 16 Position Statement (1990) Nutritional recommendations
17 18
19 20
21
22
23
24
25
26
and principles for individuals with diabetes mellitus. Diabetes Care 13 (Suppl. 1), 18-25. Lean, M.E.J. and Anderson, A.S. (1988) Clinical strategies for obesity management. Diabetic Med. $515-518. Seisdedos, N. and Roig-Fuste, I.M. (1986) Suplemento tecnico e interpretation clinica MMPI. Publication de Psicologia Aplicada, Madrid. Dixon, W.J. (Ed.) (1988) BMDP. Biomedical Computer Programs. University of California Press, Berkeley. Lissner, L., Habicht, J.P., Strupp, B.J., Levitsky, D.A., Haas, J.D. and Roe, D.A. (1989) Body composition and energy intake: do overweight women overeat and underreport? Am. J. Clin. Nutr. 49, 320-325. Klesges, R.C., Hanson, CL., Eck, L.H. and Durff, A.C. (1988) Accuracy of self-reports of food intake in obese and normal-weight individuals: effects of parental obesity on reports of children’s dietary intake. Am. J. Clin. Nutr. 48, 1252-1256. Myers, R.J., Klesges, R.C., Eck, L.H., Hansen, C.L. and Klem, M.L. (1988) Accuracy of selfreports of food intake in obese and normal-weight individuals: effects of obesity on self-reports of dietary intake in adult females. Am. J. Clin. Nutr. 48, 1248-1251. Shah, M., Miller, D.S. and Geissler, C.A. (1988) Lower metabolic rates of post-obese versus lean women: thermogenesis, basal metabolic rate and genetics. Eur. J. Clin. Nutr. 42, 741-752. Elliot, D.L., Goldberg, L., Kuehl, K.S. and Bennett, W. ( 1989) Sustained depression of the resting metabolic rate after massive weight loss. Am. J. Clin. Nutr. 49, 93-96. Bray, G.A. (1989) Genetic and hypothalamic mechanisms for obesity-finding the needle in the haystack. Am. J. Clin. Nutr. 50, 891-902. Moreiras-Varela, 0. (1989) The mediterranean diet in Spain. Eur. J. Clin. Nutr. 43 (Suppl. 2), 83-87.
1992 Elsevier Science Publishers
157
B.V. All rights reserved 0168-8227/92/$05.00
DIABET 00588
Behaviour modification in obese subjects with type 2 diabetes mellitus A.L. Calle-Pascual ‘, C. Rodriguez ‘, F. Camacho I, R. Sanchez ‘, P.J. Martin-Alvarez2, E. Yuste ‘, I. Hidalgo 3, R.J. Diaz 3, J.R. Calle4 and A.L. Charro4 ’ Unit of Endocrinology and Nutrition, ‘C.S. I.C. Madrid, ‘Psychiatric Unit, Hospital Ntra Sra de Sonsoles, University of Salamanca,
Avila and 4Hospital Clinic0 Universitario, Madrid, Spain
(Received 29 June 1990) (Revision accepted 11 September
1991)
Summary We have followed prospectively, 46 obese, type 2 diabetic patients for a 55-week period, in order to evaluate the efficiency of an educational programme based on behaviour modification to enhance weight loss and changes of other cardiovascular risk factors. No patient received pharmacological treatment during the study. At the end of the follow-up the patients obtained an average weight loss of 9.250 kg (range: 0.500-17.500 kg); the BMJ was reduced from 34.2 + 0.8 kg/m2 to 30.6 + 1.1 kg/m2 (P < 0.01); fasting serum glucose descended from 7.9 + 0.4 to 6.1 k 0.5 mM (P < 0.05); SBP (systolic blood pressure) decreased from 145.7 + 3 to 126.4 k 5.1 mmHg (P < 0.01); DBP (diastolic blood pressure) decreased from 83.5 ? 2.5 to 65 + 2.6 mmHg (P < 0.01); triglyceride levels were lowered from 164.5 & 12 to 109.7 k 10 mg/dl (P < 0.01); HDL-cholesterol levels increased from 1.27 k 0.05 to 1.53 k 0.12 mM (P < 0.01). Serum glucose 2 h after a 75 g glucose oral load decreased from 14.9 + 0.6 to 12.7 k 0.9 mM (P < 0.05) on week 35 of follow-up. Twelve patients no longer presented a diabetic curve (8 normal oral glucose tolerance test (OGTT) curves, and 4 impaired glucose tolerance (IGT) curves). No significant changes in the parameters studied were obtained in the group of patients on conventional treatment. Patients from the intervention group losing less than 4 kg of body weight displayed an increase in dependence and social introversion scores according to the Minnesota multiphasic personality inventory (MMPI) compared to those who lost more than 4 kg (possibly as a consequence of failure to attain the aims of the educational programme). Our results permit us to conclude that an educational programme using behaviour modification can be useful in the weight reduction of obese type 2 diabetic patients, thereby improving blood glucose control and reducing other cardiovascular risk factors.
Key words: Behaviour
modification;
Correspondence to: A.L. Calle-Pascual, Lagos s/n, 28040 Madrid, Spain.
Obesity; Type 2 diabetes mellitus; Cardiovascular
Servicio de Endocrinologia
y Nutrition
risk factor
2%, Hospital Clinic0 Universitario,
c/-Martin
158
Introduction
Obesity is the most commonly-occurring nutritional disease in developed countries [ 11. It is often associated with type 2 diabetes mellitus, which increases mortality rate. However, increased death rate can be reduced by weight loss [ 21. Furthermore, 75 % of type 2 diabetic patients are obese [ 31. Weight loss can prolong life expectancy [4] and can improve glucose tolerance [ 51. For these reasons, the aim of treatment of overweight type 2 diabetic patients must be reduction of body weight as well as of other cardiovascular risk factors [6]. A retrospective study has recently demonstrated that each kg of weight lost lengthened life-expectancy by four months [4]. Yet weight loss is not easy to achieve in type 2 diabetic patients, and the results of weight reduction programmes have been contradictory [7-Ill. It has been said that diabetic patients present greater difficulty in losing weight than non-diabetic subjects [ 9, lo] implying the need for pharmacological treatment of obesity [ 121. The reasons for discrepancies in results may stem from the differences in the educational programmes used, since success is greater if followup is more intense, and more so if home visits are included [ 13-l 51. However, it may not be feasible to apply an intensive approach to large diabetic populations. Recently, the use of an educational programme with behaviour modification has been recommended for type 2 diabetic patients with obesity [ 16,171, but there are no data on the success rate of these programmes in diabetic patients. The aim of our work has been to study the efficiency of an educational programme with behaviour modification in type 2 diabetic patients with obesity on weight loss and on other cardiovascular risk factors.
Material
and Methods
We designed a prospective study in which all patients that came to our hospital between January and June, 1988 were included, provided
that the reason for consultation was obesity and that they were diagnosed as having diabetes mellitus based on a fasting serum glucose level (between 7.7 and 8.8 mM) or serum glucose response to 75 g of glucose (if the fasting serum glucose level was below 7.7 mM) in accordance with the criteria of the National Diabetes Data Group. The protocol was approved by the Clinical Trials Board and carried out following the principles of the Helsinki Declaration. No patient received pharmacological treatment during the study. Intervention group A total of 46 patients, 10 men and 36 women, fulfilled the requirements and completed the study. They were 55.09 + 9.7 years of age. The average weight was 81.21 & 1.77 kg. The BMI averaged 34.21 k 0.8 kg/m2 (M k SEM). On the first day of consultation, data about the patients’ caloric consumption were gathered retrospectively. Note was taken of what the patients had eaten during the previous week and on the previous day. We also, prospectively, analyzed and noted the diet of three non-consecutive days between the first visit and the beginning of the educational programme (one or two weeks after the first visit). Design of the educational programme The design was similar to the one used for obese patients and previously published [5]. It was taught by paramedical personnel (nurses) and consisted of four 150-180 min sessions in one week. The first session was individual and during it personal characteristics of each patient were noted. The three remaining sessions were done in groups of five to eight patients of similar age and cultural background. In these meetings we tried to modify eating behaviour. In the first meeting, patients were taught dietetic principles including food composition, calculation of caloric content, ‘filling’ capacity of different foodstuffs and calculation of caloric expenditure. The remaining two sessions were oriented towards teaching self-control over excessive eating patterns. This part of the
159
programme consisted of five phases. During phase one we tried to reinforce the patients’ selfcontrol over the need to eat. We advised postponed initiation of food ingestion in a progressive manner from one to five min, while the patient was in front of the food. In phase two the goal was to create awareness of each meal by proposing that the patient himself prepare his food. During phase three we recommended that eating was not to be simultaneous with other activities. In the fourth phase the patients were taught exercises intended to alter their cooking habits, deleting condiments and foods with high caloric content. Phase five was directed towards the detection of ‘dangerous moments’ when the patient ingested large amounts of food; we advised them to carry out simultaneous parallel activities. The patients did not receive rules nor diets in writing. Five, 10, 35 and 55 weeks after having carried out the educational programme, retraining on these latter aspects was given in group sessions. At each visit we measured body weight, blood pressure, white blood cells and red blood cells (Coulter), Na, K, Ca, P, BUN, uric acid, glucose, cholesterol, triglycerides (Hitachi, autoanalyzer) and HDL-cholesterol (enzymatic method). An OGTT with 75 g of glucose was performed at the beginning and after 5 and 35 weeks of follow-up. Psychological projile
After 55 weeks of follow-up the Minnesota MultiPersonality Inventory (MMPI) phasic questionnaire in the collective form taken from the Spanish version by TEA [ 181 was tilled out by 24 women; as a control group we chose 24 obese type 2 diabetic women at the beginning of their educational program and with a similar age and BMI. This questionnaire is designed specially to make possible an estimation of the commonly recognized syndromes in subjects with clinical problems. The superior dimensions of personality were calculated beginning with the first-order factors. Control group
Conventional treatment for obese type 2 diabetic patients on diet alone, in our clinic includes two
meetings dedicated to dietetic instruction and exercise. All patients receive tables of equivalence and a set of six diets of 1000 calories divided into 6 meals with 60% carbohydrate content. Laboratory data are obtained after each 5 kg of weight loss, and at least once a year. We show the laboratory data at 55 weeks of follow-up, because at this time these data were available for all patients. Included in this control group were 28 obese type 2 diabetic patients, 7 men and 21 women, 53.03 k 6.78 years of age, with a body weight of 80.925 & 1.59kg and with a BMI of 34.13 + 0.75 kg/m2. No patient received pharmacological agents during this year period. The statistical analysis was done using the BMDP3D program from BMDP package [ 193, in order to test the equality of group means (Student’s two-sample t-test). This program was run on a CDC Cyber 180/855 computer (Control Dada Iberica, Madrid, Spain).
Results Intervention group
The mean weight loss was 9.250 kg (range: 0.500-17.500 kg) during follow-up. The BMI decreased with statistical significance from 34.2 + 0.8 to 30.6 + 1.1 kg/m2 (P < 0.01). Likewise, after 55 weeks of follow-up, the following changes were observed: FSG (fasting serum glucose) dropped from 7.9 + 0.4 to 6.1 k 0.5 mM (P < 0.05); SBP (systolic blood pressure) fell from 145.7 _+3 to 126.4 _+5.1 mmHg (P < 0.01); DBP (diastolic blood pressure) was lowered from 83.5 _+2.5 to 65 f 2.6 mmHg (P < 0.01); triglyceride levels decreased from 164.5 k 12 to 109.7 + 10 mg/dl (P < 0.01) and HDL-cholestelevels rol rose from 1.27 _+0.05 to 1.53 2 0.12 mM (P < 0.01). The 2-h value for serum glucose after a 75 g glucose oral load decreased from 14.9 _+0.6 to 12.7 _+0.9 mM (P < 0.01) in week 35 of follow-up (Table 1). Based on the data provided by the OGTT, 12 patients ceased to be considered as having diabetes mellitus (8 normal OGTT curves and 4
160 TABLE
1
Changes in body weight and in laboratory
data during the follow-up
Time (weeks) 0 BW (kg) BMI (kg/m’) FSG (mM) 2-h OGTT (mM) SBP (mmHg) DBP (mmHg) TG (mg/dI) Chol (mM) HDL-Ch (mM) CholjHDL-Ch
81.2 & 34.2 + 1.9 * 14.9 + 145.7 f 83.5 + 164.5 f 6.12 f 1.27 k 5.0 +
5 1.7 0.8 0.4 0.6 3.0 2.5 12.0 0.14 0.05 0.2
71.5 + 32.9 f 6.7 k 13.5 & 134.7 f 15.4 + 153.7 + 5.73 + 1.17 f 5.1 +
10 1.s** 0.9** 0.3* 0.7* 3.1** 2.2** 11.0 0.16** 0.05 0.2
35
74.2 + 2.0** 31.6 k l.O** 6.5 f 0.4** 131.7 & 72.4 f 144.1 2 5.82 + 1.30 * 4.6 i
2.9** l.l** 11.0 0.20 0.05 0.2
73.1 31.3 6.7 12.7 137.4 80.5 140.2 6.17 1.29 4.9
55 f + f & * + k + + f
1.9** 1.0** 0.4** 0.9* 3.5 2.6 12.0 0.21 0.05* 0.2
71.4 + 2.0** 30.6 f l.l** 6.1 + 0.5* 126.4 65.0 109.7 6.21 1.53 4.4
f 5.1** f 2.6** f 10.0** f 0.29 f 0.12** f 0.3
BW, body weight; BMI, body mass index; FSG, fasting serum glucose level; 2-h OGTT, 2-hour serum glucose response to 75 g oral glucose load; SBP, systolic blood pressure; DBP, diastolic blood pressure; TG, triglyceride level; Chol, cholesterol level; HDL-Ch, HDL-cholesterol level. Results expressed as mean t SEM
intolerant OGTT curves). There were no significant changes in the other laboratory data studied. One year later these patients presented a significant increase in the dependence score (Dy), the higher the score, the higher the dependence on the treatment team [ 181, in comparison to those who did not receive educational courses (33.6 1 2 1.6 vs 27.78 k 1.4; P < 0.05) (this increase reflects the higher score seen in patients who did not attain a 4 kg weight loss). A higher score in the social introversion scale (the higher the score, the higher the social isolation because of their disease) was seen in patients who did not attain a 4 kg weight loss (43.66 + 2.5) compared to those patients who lost more than 4 kg of body weight (35.71 + 3.2; P < 0.05). A negative correlation between body weight loss (BWL) and dependence score (Dy = 41.28 - 4.676 BWL; Y = - 0.693; P < 0.05) and between BWL and social introversion (SI) score (SI = 46.97 - 5.049 BWL; r= - 0.772; P < 0.05) was found. Conventional treatment group Patients in conventional treatment failed to show any significant changes in the parameters studied:
body weight (80.925 & 1.59 vs 81.070 k 1.20 kg), BMI (34.13 k 0.75 vs 34.32 k 0.64 kg/m*), FSG (7.78 k 0.71 vs 7.75 k 0.46 mM), 2-h value for serum glucose after a 75 g glucose oral load (14.54 2 0.19 vs 14.48 f O.l6mM), SBP (148.03 2 3.72 vs 145.35 k 3.39 mmHg), DBP (85.35 k 2.09 vs 86.07 _I 2.02 mmHg), triglyceride levels (166.46 f 9.06 vs 163.28 2 7.76 mg/dl), cholesterol levels (6.26 f 0.06 vs 6.21 + 0.98 mM), HDL-cholesterol levels (1.29 + 0.02 vs 1.30 k 0.04 mM) and cholesterol/HDL-cholesterol ratio (4.89 + 0.12 vs 4.92 & 0.21).
Discussion Our study confirms previous results obtained with obese patients proving the efficiency of behaviour modification programmes in weight loss and in reducing other cardiovascular risk factors [ 51. Lesser caloric intake per kg of body weight of obese patients than lean people has been reported. Recently it has been said that this unexpected result cannot be explained solely by underreporting [ 20-221. Other factors can be involved
161
[23-251. We venture the hypothesis that the cornerstone of the problem is that many foods are ingested rather subconsciously by the obese person. Therefore, our programme with behaviour modification was structured in such a way as to force the patient to make an effort (e.g. preparation of the meal.. . ) before ingesting the meal, and to become aware of the activity of eating. We did not consider it appropriate to induce phobias against or adverse reactions to foodstuffs. We included notions on caloric content and expenditure to favour ingestion of foods with less calories. regular physical exercise (e.g. avoiding taking the subway or bus, or to get out of public transport one or two stops before the destination; not to use elevators, etc.) was also recommended. In order to facilitate the interpretations of the results of our educational programme, we chose obese patients diagnosed as having diabetes mellitus based on the OGTT (with a FSG level below 7.7 mM) or with a FSG level between 7.7 and 8.8 mM, thereby being ethically tolerable to have pharmacological hypoglycaemic treatment withheld. Nor did they receive anorexigenic agents. Therefore, we can state that our results are solely the consequence of the effects of the educational programme. Our patient attained a weight reduction of 9.250 kg (range 0.500-17.500 kg) and an improvement in cardiovascular risk factors. In the first 5 weeks of follow-up, we noted a non-significant decrease in total cholesterol level, at the expense of its HDL fraction, which could be due to weight reduction as well as to the acute effect of the reduction in the consumption of olive oil that is customary in the mediterranean diet [26]. Reduced olive oil intake must be taken into account when we recommend changes in the eating habits, because it could increase the atherogenic index, even if only temporarily. The weight reduction obtained by our patients produced a significant reduction in FSG levels as well as in the 2-h post-75 g oral glucose load; for this reason 12 patients were no longer considered diabetic patients at week 35 of follow-up. This confirms that simple weight loss can revert the
diabetic state [ 51. Similarly, the improvement in the other cardiovascular risk factors obtained in our study may be related to the educational programme induced weight loss as well as to modifications in eating habits (e.g. reduced salt and fat consumption) and regular physical exercise. The psychological changes found in our study were observed in the patients unable to lose weight or whose weight loss was less than 50% of the average loss. These patients had high scores in the dependence and social introversion scales. We may infer that the patients who do not reach the goals of the educational programme (e.g. lose weight) become more dependent and introverted than those who do reach the goals. This could be considered to be a side effect of the educational programme and may occur when the aims are too difficult for the patients. This fact must be taken into account when planning group education proposing variable goals. In summary, our study supports the efficiency of behaviour modification in weight reduction programmes and in reduction of cardiovascular risk factors in type 2 diabetes mellitus. Furthermore, this relatively simple programme can be applied in an ordinary medical office setting.
References Passmore, R. and Eastwood, M.A. (Eds.) (1986) Obesity. In: Human Nutrition and Diabetics. Churchill Livingstone. Edinburgh, London, Melbourne, New York, pp. 269-218. Blackburn, G.L. and Read, J.L. (1984) Benefits of reducing revisited. Postgrad. Med. J. 60, 13-18. Wing, R.R. (1989) Behavioral strategies for weight reduction in obese type II diabetic patients. Diabetes Care 12, 139-144. Lean, M.E.J., Powrie, J.K., Anderson, A.S. and Garthwaite, P.H. (1990) Obesity, weight loss and prognosis in type 2 diabetes. Diabetic Med. 7, 228-233. Calle-Pascual, A.L., Rodriguez, C., Hernandez, M.J., Martin, P.J., Yuste, E., Garcia, M.A., Matias, J., Martin, P. and Sanchez, R. (1989) Programme of education for obese patients. Preliminary results after one year. Diabete Metabol. 15, 403-408. Consensus Statement (1990) Role of cardiovascular risk factors in prevention and treatment of macrovascular
162 disease in diabetes. Diabetes Care 13 (Suppl. 1). 53-59. 7 Multi-Centre Study (1983) U.K. prospective study of therapies of maturity-onset diabetes. Diabetologia 24, 404-4 11. 8 Kronsbein, P., Miihlhauser, I., Venhaus, A., Jorgens, V., Scholz, V. and Berger, M. (1988) Evaluation of a structured treatment and teaching programme on noninsulin-dependent diabetes. Lancet ii, 1407-1411. 9 Wing, R.R., Marcus, M.D., Epstein, L.H. and Salata, R. ( 1987) Type 2 diabetic subjects lose less weight than their overweight non-diabetic spouses. Diabetes Care 10, 563-566. 10 Henry, R.R., West-Kent, T.A., Scheaffer, L., Kolterman. O.G. and Olefsky, J.M. (1986) Metabolic consequences of very low calorie diet therapy in obese non-insulin dependent diabetic and non-diabetic subjects. Diabetes 35, 155-164. 11 Glasgow, R.E., Toobert, D.J., Mitchell, D.L., Donnelly, J.E. and Calder, D. (1989) Nutrition education and social learning interventions for type II diabetes. Diabetes Care 12, 150-152. 12 Carpenter, M.A. and Bodansky, H.J. (1990) Drug treatment of obesity in type 2 diabetes mellitus. Diabetic Med. 7, 99-104. 13 Heller, S.R., Clarke, P., Daly, H., Davis, I., McCulloch, D.K., Allison, S.P. and Tattersall, R.B. (1988) Group education for obese patients with type 2 diabetes. Greater success at less cost. Diabetic Med. 5, 552-556. 14 Hadden, D.R., Blair, A.L.T., Wilson, E.A. et al. (1986) Natural history of diabetes presenting age 40-69 years: a prospective study of the influence of intensive dietary therapy. Quart. J. Med. 59, 579-598. 15 Wilson, E.A., Hadden, D.R., Merrett, J.D., Montgomery, D.A.D. and Weaver, J.A. (1980) Dietary management of maturity-onset diabetes. Br. Med. J. 280, 1367-1369. 16 Position Statement (1990) Nutritional recommendations
17 18
19 20
21
22
23
24
25
26
and principles for individuals with diabetes mellitus. Diabetes Care 13 (Suppl. 1), 18-25. Lean, M.E.J. and Anderson, A.S. (1988) Clinical strategies for obesity management. Diabetic Med. $515-518. Seisdedos, N. and Roig-Fuste, I.M. (1986) Suplemento tecnico e interpretation clinica MMPI. Publication de Psicologia Aplicada, Madrid. Dixon, W.J. (Ed.) (1988) BMDP. Biomedical Computer Programs. University of California Press, Berkeley. Lissner, L., Habicht, J.P., Strupp, B.J., Levitsky, D.A., Haas, J.D. and Roe, D.A. (1989) Body composition and energy intake: do overweight women overeat and underreport? Am. J. Clin. Nutr. 49, 320-325. Klesges, R.C., Hanson, CL., Eck, L.H. and Durff, A.C. (1988) Accuracy of self-reports of food intake in obese and normal-weight individuals: effects of parental obesity on reports of children’s dietary intake. Am. J. Clin. Nutr. 48, 1252-1256. Myers, R.J., Klesges, R.C., Eck, L.H., Hansen, C.L. and Klem, M.L. (1988) Accuracy of selfreports of food intake in obese and normal-weight individuals: effects of obesity on self-reports of dietary intake in adult females. Am. J. Clin. Nutr. 48, 1248-1251. Shah, M., Miller, D.S. and Geissler, C.A. (1988) Lower metabolic rates of post-obese versus lean women: thermogenesis, basal metabolic rate and genetics. Eur. J. Clin. Nutr. 42, 741-752. Elliot, D.L., Goldberg, L., Kuehl, K.S. and Bennett, W. ( 1989) Sustained depression of the resting metabolic rate after massive weight loss. Am. J. Clin. Nutr. 49, 93-96. Bray, G.A. (1989) Genetic and hypothalamic mechanisms for obesity-finding the needle in the haystack. Am. J. Clin. Nutr. 50, 891-902. Moreiras-Varela, 0. (1989) The mediterranean diet in Spain. Eur. J. Clin. Nutr. 43 (Suppl. 2), 83-87.
